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Abstract

Background

Research demonstrates that tobacco packaging elements (including health warning labels,
descriptive characteristics, and corporate branding) are associated with knowledge
of health risks and product appeal with cigarettes. Yet, little research has assessed
this with smokeless tobacco (SLT) packaging. This study evaluates the association
between three SLT packaging elements with knowledge of health risks and perceptions
of novelty and appeal. Additionally, we assess how effects of these messages may differ
across age groups, including youth (14-17 years), young adults (18-25 years), and
older adults (26-65 years).

Results

More respondents selected the pack with the graphic warning label as the pack to make
them consider the health risks associated with SLT use, attract their attention, and
be least attractive to a smoker. The product with the text warning label was the product
someone their age would want to be seen using and would appeal to peers. The SLT pack
with the flavor descriptor was not associated with health risks associated with product
use. The pack with corporate branding was selected as more appealing, to attract attention,
and one they would want to be seen using; the plain pack was less attractive to smokers.
Youth and young adults were more likely to indicate that pack elements affected their
perceptions of appeal and risk associated with SLT products.

Conclusion

These results suggest that SLT pack characteristics have a measurable effect on perceptions
of health risk and product appeal. Future research should assess these findings in
the context of harm reduction. Specifically, research is needed to determine whether
pack elements on SLT products can effectively convey risk and harm.

Keywords:

Background

Cigarette smoking and exposure to secondhand smoke remains the leading cause of preventable
death in the United States killing 443,000 people in the U.S. annually [1,2]. Some research suggests that use of smokeless tobacco (SLT) products, such as chewing
tobacco and snus, are less harmful and may serve as a potential cessation or substitution
strategy for cigarette users [3,4]. However, while SLT products may pose less harm than conventional cigarettes, they
are associated with increased risk for illnesses including oral cancer, esophageal
cancer, pancreatic cancer, and heart disease, among others [5-8].

Due to the fact that SLT products do pose some level of harm, it is critical that
advertising and marketing materials effectively convey this information to consumers.
Given increased commercial marketing restrictions, product packaging has become one
of the primary mechanisms for communications by the tobacco industry. Previous research
on cigarette packaging has shown that elements of the package influence consumers’
ideas about appeal, novelty, and health risks associated with use [9-21]. Elements of tobacco packaging that are critical to industry communications include
descriptive characteristics (e.g., strength, flavors) and corporate branding (name,
colors, and structural design). Only one study to date has done so with SLT products
[22].

Warning labels

Health warning labels located on tobacco packages are one of the few and most cost-effective
avenues available to governments and public health advocates to communicate the health
risks associated with product use. Research on cigarette packaging consistently finds
that highly visible health warnings labels are effective for informing consumers about
the health risks associated with smoking and promoting cessation [10-12,23]. In addition, studies demonstrate that the influence of the public health warnings
increase as the size of the warning labels increase [9], and pictorial health warnings are consistently more effective than text warnings
alone [11,13,14]. To date, only one study has assessed how pictorial warning labels influence perceptions
of SLT [22]. The findings from that study suggest that pictorial health warning labels are associated
with reduced appeal of SLT products and increased perceived risks associated with
use [22].

Flavor descriptor terms

Research examining flavor descriptor terms on tobacco packaging shows that they have
also been linked with product appeal and perceived health risks. In addition, tobacco
flavors contribute to the palatability of tobacco products, making them more attractive
to non-users and facilitating uptake [24]. The sale of flavored cigarettes, except menthol flavored cigarettes, was banned
by the Family Smoking Prevention and Tobacco Control Act (FSPTCA) of 2009 because
they are particularly appealing among youth. For example, research shows that 17-year-old
smokers are three times more likely to use flavored cigarettes than smokers over age
twenty-five [25].

Between 2000-2006, there was a 140% increase in the number of sub-brands of SLT from
20 in 2000 to 48 by 2006 [26], with the majority of these including some sort of flavor added to the tobacco product
[27]. Furthermore, there is research that suggests use of menthol or mint flavorings in
SLT products may be related to initiation and use of SLT [26]. Despite the rise in flavored SLT products, there remains a dearth of evidence about
how flavors and their associated descriptor terms contribute to perceptions of appeal
and risk associated with SLT product use.

Corporate branding

Research suggests that plain packaging, which standardizes the appearance of tobacco
products between brands and eliminates corporate imagery, may be an effective regulatory
tool in diminishing brand appeal and reducing misperceptions about health risks that
may be garnered from cigarette branding and package design [9,15,16]. For example, Wakefield and colleagues found that plain packaging was significantly
more effective in reducing brand appeal than increasing the size of the public health
warning, and that plain packaging lowered intentions to buy cigarettes [15]. Investigators have also demonstrated that plain packaging is effective in reducing
false risk perceptions associated with branding and in reducing brand appeal, particularly
among youth, for cigarettes [9,17]. Two systematic reviews of the literature (reviewing 54 studies that show the impact
of plain tobacco packaging) have found that plain packaging as opposed to branded
packs (1) reduces package appeal, (2) increases visibility and salience of health
warnings, and (3) reduces confusion about the harm associated with use that has been
shown to result from packs with corporate branding [28,29]. These findings prompted Australia to enact legislation in December 2012 that requires
tobacco products be packaged in drab brown-colored “plain” packs, with the brand name
and variety written in a standardized font. However, the research on plain packaging
has not addressed smokeless tobacco. Additionally, the use of smokeless tobacco in
Australia is virtually nonexistent and additional research is needed to assess the
effects of plain packaging on perceptions and behaviors of SLT users [12].

Initiation of tobacco use most frequently occurs among youth – a group susceptible
to messages and misleading information (e.g. tobacco package coloring or descriptors
which may imply that a products is lower risk) presented on tobacco product packages
[17,30,31]. Public health advocates have reiterated the importance of curbing youth uptake of
tobacco, including combustible and non-combustible products, to avoid long and short-term
health and social costs [32]. The importance of pack elements in communicating product information to consumers
has been well documented in studies that focus on combustible tobacco products [9,11,15,33]. Evaluating the impact of packaging on perceptions of appeal and health risk among
SLT products has been marked as a research need [34] given recent data showing increased rates of SLT use among youth and young adults.
For example, the 2009 Youth Risk Behavior Surveillance reported that SLT use increased
among high school students from 6.7% to 8.9% between 2003 and 2009, with an increase
from 11% to 15% among male students (http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5905a1.htmwebcite). Additionally, research shows that there was an increase from 13.6% to 15.4% among
18-25 year old non-Hispanic white men [35]. Increases in SLT use are particularly prominent among White high school males [32]. A primary focus of the FSPTCA is to discourage tobacco uptake and use among youth
and young adults, and to regulate health warning labels on tobacco products to accurately
convey the risks associated with use [27]. As it stands, some research suggests that young adults have little understanding
of the risks associated with traditional and new SLT products [17,18,31]. More research is needed to evaluate how characteristics of SLT product packaging
influence perceptions of health risks, particularly among high-risk groups like youth
and young adults.

The current research evaluates the association between three SLT packaging elements
–warning label format, flavor descriptors, and corporate branding – with perceptions
of health risks, novelty and appeal. Additionally, because it is particularly important
to curb tobacco uptake among youth and young adults, we assess how messages conveyed
by these packaging elements may differ across age groups, including youth (14-17 years),
young adults (18-25 years), and older adults (26-65 years).

Methods

The study utilized a Web-based survey methodology and data were collected over a one-week
period in July 2010. Participants were recruited from a panel maintained by Global
Market Insite (http://www.gmi-mr.com/global-panel/index.phpwebcite), a private company that maintains global consumer and specialty panels. Membership
in their panel involves a double opt-in process where interested parties complete
an online registration form, and then activate their account by clicking a link provided
by GMI via e-mail. U.S. residents were targeted for inclusion. All participants were
invited to respond to the survey via email and were deemed eligible if they were between
the ages of 14 and 65 and provided consent. In the case of minors, parents were e-mailed
a statement describing the survey risks and benefits of participation, compensation,
and confidentiality prior to their child engaging in the survey. Parental consent
and youth assent was obtained prior to participation in the survey. The sample was
specifically designed to represent four age groups: 14-17 years (20%), 18-21 years
(20%), 22-25 years (20%), and 25-65 years (40%). A total of 1000 participants responded
to the survey. The study protocol was approved by the Institutional Review Board at
Roswell Park Cancer Institute, Buffalo, NY.

Procedure

Participants were first asked questions regarding their knowledge of the health risks
associated with tobacco products and reasons for tobacco use. Following this series
of questions, participants viewed, in random order, each of the products outlined
in Figure 1. Six SLT products were included (Skoal Long Cut Mint, Camel Snus Frost, Marlboro
Snus Peppermint, Camel Strips Fresh, Camel Orbs Fresh, and Stonewall Wintergreen Hard
Snuff). Participants were provided with a brief one sentence description of how to
use each product, given that many of the products may have been unfamiliar, and were
then asked to indicate which product was the most appealing and which was the least
appealing. The tobacco products selected as ‘most appealing’ and ‘least appealing’
were then presented to participants with three distinct packaging variations: graphic
vs. text warning labels, flavor descriptor vs. no descriptor, and branded SLT pack
vs. plain SLT pack (Figure 1). Participants were asked a series of questions regarding their perceptions of appeal
and health risks of the displayed product based upon the different packaging formats
(see Questions asked for each SLT packaging condition for the list of questions).
The ordering of the packaging sets varied randomly between participants to minimize
potential ordering effects. Because the most appealing product is one that participants
would be more likely to use, the results reported focus on participants’ responses
to the most appealing product selected. At the end of the session, participants were
thanked and compensated with $5 in GMI "Market Points", which can be redeemed for
a check mailed to them in USD.

*Respondents were asked to pick between two packs or select ‘no difference’.

Measures

Knowledge of health risks associated with smokeless tobacco

Respondents were presented with a list of health effects and diseases that may or
may not be caused by using smokeless tobacco. These health conditions included: lung
cancer, oral cancer, pancreatic cancer, heart disease, emphysema, and lung disease.
Respondents were asked, “Based on what you know or believe, does smokeless tobacco
use cause…?” with a yes, no, or don’t know response option.

Package elements

Upon selecting a product as most and least appealing, respondents were presented with
each of three packaging conditions, individually tailored to reflect respondents’
selected most appealing product. Within each condition, respondents were presented
with a series of questions and asked to select one pack within the condition for each
question or indicate if there was no difference. Respondents were also presented with
the three packaging conditions and asked this same series of questions for their selected
least appealing product. Those results are not presented here, but largely mirrored
the results for the most appealing product.

Statistical analyses

Data were cleaned and analyzed using SPSS 21.0 (SPSS, Inc., Chicago, IL). Differences
in demographic and tobacco use variables, as well as differences regarding knowledge
of SLT and perceptions of appeal, novelty, and health risks associated with SLT pack
design characteristics, were tested using chi-square tests of independence for each
categorical variable. The chi-square test allows for comparisons among multiple groups.
For example, in the case of branded packaging vs. plain packaging, respondents were
given the option to select whether (1) the branded pack, (2) the plain pack, or (3)
the packaging had ‘no difference’ on their opinion of the product. This test evaluates
the hypothesis that the frequencies do not differ from their expected values (here
specified to be equal across conditions such that each category would reflect 33.3%
of respondents’ selections, χ2 statistic, p-value < 0.05). These analyses were performed for the overall sample and across age
groups. We specifically assessed whether or not respondents endorsed a specific package
design feature versus selecting “no difference” between packs to be associated with
increased/decreased risk and appeal. Multinomial regression was employed to evaluate
the association between packaging elements and participant age. These models were
adjusted for sex and race/ethnicity (White non-Hispanic, Black non-Hispanic, Hispanic,
other non-Hispanic), and tobacco use status. The outcome variable was the different
pack selections (e.g. graphic, text, no difference [referent]). In other words, each
of two variant options, (e.g. graphic and text warnings), were compared to selecting
no difference between packs. The subgroups (e.g. age) were then compared on their
likelihood of selecting a given option versus no difference between the two variants.
While the data were specifically sampled to assess perceptions between different age
groups, few significant differences were identified in knowledge related to SLT use
and perceptions of risk and appeal between 18-21 year olds and 22-25 year olds. As
a result, these two groups were collapsed into one to represent young adults for the
analyses.

Results

Sample characteristics

Characteristics of the sample are presented in Table 1. The majority of the sample (74%) was White non-Hispanic, 7% were Black non-Hispanic,
11% were Hispanic, and 9% reported Other non-Hispanic. Half of the sample was female
(50%). Three-fourths of respondents (75%) reported having tried a cigarette at some
point in their lifetime, and half (50%) reported having smoked daily (at least one
cigarette per day for 30 days). Nearly 17% of respondents reported using an SLT product
within the past 30 days (used SLT at least 1 day within the past 30 days).

Respondents who had used SLT in the past 30 days and intended to use SLT in the future
were more likely to be between 18 and 25 years of age compared with other age groups,
male, Hispanic, and report “Other” for their race. They were also more likely to have
previously tried cigarette smoking and to have smoked daily.

Table 2 displays the SLT products that respondents selected as the most appealing overall
and across the different age groups. Respondents’ overwhelmingly selected dissolvable
tobacco (Camel Strips and Camel Orbs, 56%) as the most appealing products. Chi-square
tests between age groups showed that young adults (18-25 year olds) were more likely
to select Camel Strips (p = .033) and Camel Snus (p = 0.016) than older adults (26-65 year
olds) and more likely to select Camel Snus (p = .039) than youth (14-17 year olds).
Youth were more likely to select Stonewall (p = .048) than young adults. There were
no significant differences in selections between youth and older adults. Older adults
were more likely to select Marlboro Snus (p = .013) and Stonewall (p = .001) than
young adults. Analyses also showed that the most appealing product selections varied
based on tobacco use status for three products. Non-tobacco users were significantly
more likely to select Camel Strips (p = .017) and Camel Orbs (p = .036) and tobacco
users (use SLT or cigarettes) were more likely to select Camel Snus (p = .001) as
the most appealing product (data not shown). In addition, men were more likely to
select Stonewall (p = .024) and Skoal (p = .006) and women were more likely to select
Camel Strips (p = .030).

Knowledge of health effects associated with SLT use

The majority of respondents correctly identified that SLT use was associated with
oral cancer (82%) and gum disease (82%). However, respondents were less likely to
identify SLT use with heart disease (47%) and pancreatic cancer (30%). Approximately
one-third incorrectly reported that SLT use was linked with emphysema (36%) and lung
cancer (37%).

Common myths and other beliefs associated with tobacco use were also assessed (response
options were: agree, neutral, disagree). Overall, 67% of respondents incorrectly reported
that nicotine was a cause of cancer. This was highest among 14-17 year olds (77%)
and lowest among 18-25 year olds (60%), while 26-65 year olds agreed 69% of the time.
Nearly one-fifth (18.5%) believed that quitting smoking by 30 years of age eliminates
the associated health risks, but no significant differences by age group were identified.
Ten percent believed that so long as someone spits, SLT use is not dangerous; this
finding was highest among 18-25 year olds (12.3%). Half (53%) believed that tobacco
companies specifically target people their age, with youth (60%) and young adults
(67%) significantly more likely to agree with this statement than 26-65 year olds
(35%) (Youth χ2 (2, N = 601) = 35.832, p < .001); (Young adult χ2 (2, N = 799) = 91.934, p < .001).

Packaging elements

Graphic vs. Text warning labels on SLT packaging

Figure 2 (and Table 3) displays participant responses for whether a SLT package with a graphic or text
warning label was more likely to have an impact on measures of appeal and health risks
associated with use. More respondents selected the pack with the graphic warning label
as the pack to make them consider the health risks associated with SLT use, attract
their attention, and be least attractive to a smoker. The product with the text warning
label was selected as the product someone their age would want to be seen using and
to appeal to peers.

Table 3.Perceptions of SLT product by pack conditions for the respondent’s most appealing
product (%)

Multinomial regression also revealed that graphic warning labels were particularly
associated with conveying the health risks of tobacco use to youth and young adults
as compared to older adults (26-65; see Additional file 1: Table S1), as compared to reporting no difference between types of warning. Compared
to older adults, youth and young adults had greater odds of selecting the pack with
the graphic warning label as dangerous to their health (OR: 1.521, CI: 1.026-2.555;
OR: 1.434, CI: 1.033-1.992) and to make them consider the health risks associated
with using the product (OR: 1.493, CI: 1.026-2.171; OR: 1.898, CI: 1.371-2.629), compared
to reporting no difference between packs. Compared with older adults, youth and young
adults noted the pack with the graphic as less attractive to smokers (OR: 1.738, CI: 1.191-2.537;
OR: 1.782, CI: 1.293-2.456), while the one with the text warning was associated with
increased odds of tasting better (OR: 1.698, CI: 1.110-2.599; OR: 1.280-2.584), appealing
to peers (OR: 1.860, CI:1.293-2.675; OR: 2.669, CI: 1.951-3.653), and for someone
to prefer to be seen using (OR: 1.783, CI: 1.242-2.552; OR: 2.326, CI: 1.707-3.169),
again as compared to seeing no difference between warning types.

Flavor descriptor

Figure 3 (and Table 3) displays the results of the impact of the flavor descriptor on perceptions of appeal
and health risk associated with the SLT product that respondents selected as most
appealing. The majority of respondents (over 50%) indicated that there was no difference
between packaging elements on their product opinions regarding health risk and perceptions
of appeal. Among those who selected a pack rather than “no difference”, the pack with
the flavor descriptor was selected as having the best taste, to be mostly likely to
attract their attention, and to be appealing to people their age.

Multinomial regression showed that youth, compared with older adults, were more likely
to report the pack with the descriptor as having the best taste (OR: 1.695, CI: 1.185-2.423),
that they want to be seen using (OR: 2.137, CI:1.427-3.199), that appeal to people
their age (OR: 2.111, CI: 1.468-3.038), and reduce the health risks associated with
use (OR: 1.762, CI: 1.005-3.087), compared to reporting no difference between packs
(Additional file 2: Table S2). Young adults had increased odds of selecting the packaging with the flavor
descriptor as attracting their attention (OR: 1.657, CI: 1.223-2.245), having the
better taste (OR: 2.0065, CI: 1.519-2.806), to want to be seen using (OR: 2.355, CI: 1.1.664-3.333)
and appealing to people their age (OR: 2.340, CI: 1.714-3.194) than older adults.
Young adults also had increased odds of reporting the pack without the descriptor
would deliver more dangerous chemicals (OR: 1.788, CI: 1.090-2.934) than older adults.

Additional file 2: Table S2. Multinomial logistic regression for perceptions of SLT packaging with or without a
flavor descriptor term.

Branded vs. Plain packaging

Figure 4 displays the results of the impact of the branded vs. plain packaging on perceptions
of appeal and health risk of the SLT product respondents selected as most appealing.
The pack that contained the corporate branding label was selected as having the best
taste, more likely to attract respondents’ attention, more appealing to people their
age, and the product that someone would want to be seen using. The plain packaging
was selected as being less attractive to smokers. Additionally, the branded pack was
reported to contain smokeless tobacco of better quality (χ2(N = 1000) = 388.142 expected = 333, observed = 401).

Multinomial regression showed that, compared to older adults, youth and young adults
were more likely than older adults to select the plain pack, rather than saying there
was ‘no difference between packs’, as having more dangerous chemicals (OR: 1.692,
CI: 1.120-2.55; OR: 1.836, CI: 1.303-2.587, all report youth then young adults), being
more dangerous to their health (OR: 2.039, CI: 1.312-3.168; OR: 2.126, CI: 1.459-3.098)
to make them consider the health risks associated with use (OR:1.859, CI: 1.243-2.782;
OR: 1.480, CI: 1.045-2.097) and less attractive to a smoker (OR: 1.451, CI: 1.012-2.080;
1.848, CI: 1.356-2.517). They selected the branded pack as having the best taste (OR: 1.960,
CI: 1.374-2.797; OR: 2.558, CI: 1.887-3.468), more likely to attract their attention
(OR: 1.646, CI: 1.132-2.394; OR: 2.503, CI: 1.800-3.482), and to want to be seen using
(OR: 2.124, CI: 1.478-3.033; OR: 3.565, CI: 2.606-4.876). In general youth and young
adults were more likely to select a pack as having an effect, rather than no difference,
on their perceptions of harm and appeal in many of the areas assessed (see Additional
file 3: Table S3).

Discussion

Reducing tobacco-attributable illness in the U.S. and worldwide relies on effective
tobacco control efforts, which includes adequately informing consumers about the dangers
associated with tobacco use, especially vulnerable and susceptible youth. Research
demonstrates that tobacco packaging elements (including health warning labels, descriptive
characteristics, and corporate branding) are associated with knowledge of health risks
and product appeal with cigarettes. Results from the current research suggest that
package design characteristics are associated with perceptions of health risk and
product appeal with smokeless tobacco packaging as well.

The current research found that graphic health warning labels were associated with
lower ratings of product appeal and elicit greater concern for health risks than text
warnings alone, consistent with previous research testing warning labels for cigarettes
[11]. Furthermore, the impact of graphic warnings was strongest among the youth and young
adults in our sample (14-25 year olds). Youth in our study reported that the products
with graphic warnings would likely taste worse and pose more harm to a user, perceptions
which may be linked with a lower likelihood of product use. A systematic review of
literature on health warning labels conducted in 2011 indicated that health warning
labels on cigarette packs can discourage youth uptake of tobacco, yet the impact of
such warning labels is dependent upon the presence of imagery, location, size, and
text of the warnings [36]. Research to date has focused on health warning labels on cigarette packs; the findings
from this study suggest that this may also be true for warnings on SLT products.

Smokeless tobacco packaging with the flavor descriptor was not associated with conveying
information regarding health risks associated with product use. This is consistent
with previous findings with cigarettes – characterizing flavors do not necessarily
alter risk perceptions around the product [37,38]. Future research should continue to evaluate how flavorings in smokeless tobacco
products may be related to perceptions of health risks and appeal.

The branded pack was more appealing and more likely to grab respondents’ attention,
while plain packaging was perceived as delivering more chemicals and making respondents
consider the health risks associated with SLT use. Corporate branding on the packaging
appeared to diminish perceptions of harm and increase positive perceptions of product
quality compared to products in plain packaging. These findings are consistent with
what other studies on combustible tobacco products have shown with regard to the influence
of product packaging on consumer perceptions of the product [14,17,20,21,31]. In December 2012 plain packaging legislation was passed in Australia with the intent
to reduce the appeal of packaging to consumers and increase the noticeability and
salience of health warnings, among others (see Tobacco Plain Packaging Act 2011 for
more detail: http://www.comlaw.gov.au/Details/C2011A00148webcite). The real life effects of plain packaging on initiation, cessation, and relapse
remain to be seen.

While this research illustrated that, among all age groups, SLT packaging elements
were associated with product-related beliefs, a key finding was that youth and young
adults were often more likely than older respondents to indicate that these elements
would have an effect on their perceptions in each of the product conditions. This
is of particular importance because, according to the most recent U.S. Surgeon General’s
report, the majority of new smokeless tobacco users are youth and young adults [32]. If packaging elements are effective in conveying messages to young people, incorporating
components that accurately convey the risk associated with use and reduce product
appeal may result in a reduction in uptake among non-users.

Respondents overwhelmingly selected the new dissolvable tobacco products, Camel Strips
and Camel Orbs, as the most appealing, accounting for over half of selections (62%).
This product was only available in two test markets in the country at the time of
this survey. Therefore, respondents found this product appealing simply by looking
at the package and reading a one sentence description about how each product is used.
Furthermore, when presented with the branded packaging condition, those who had selected
the Strips and Orbs also selected the branded pack as particularly appealing to those
their age and as the one they would want to be seen using. These tobacco products
have packaging that closely resembles nontobacco products like breath strips or candy
and may be alluring to youth. Further research should examine how these products are
perceived after trial and how integrated corporate branding with other tobacco products
(such as use of the Camel brand) influences perceptions and intention to try these
products.

Limitations

Several limitations should be considered. First, this was a web-based survey with
an internet panel that was strategically designed to assess particular age groups,
and does not reflect a representative sample of the US population. Because this survey
was web-based, only those with access to a computer were able to participate, potentially
underrepresenting individuals from lower socioeconomic classes. Additionally, because
this was an opt-in internet panel, it is possible that there is some confounding present
between internet access and panel composition.

Also, because this was a cross-sectional survey, we are unable to draw conclusions
regarding the causation between packaging elements and perceptions of appeal and harm.
The current data speak only to associations between packaging elements and perceptions.
Another limitation is that tobacco use rates in this survey were markedly high and
not reflective of the general population. Half of our sample had smoked daily at some
point and three-quarters and smoked at some point in their lifetime. In addition,
17% of participants had used SLT in the past 30 days, though use in the general population
among adults is 3.5%. Future research should apply these methods to a more broadly
generalizable population. Despite these limitations, these findings highlight the
importance of smokeless tobacco packaging in conveying information to consumers or
creating impressions, and have important implications for future studies and tobacco
control policy efforts.

Conclusions

Smokeless tobacco packaging elements appear to be associated with perceptions of harm
and product appeal, especially among young people. To date, only one other study has
assessed how pictorial health warnings influence perceptions of smokeless tobacco
with similar results [22], and, this is the first study to evaluate other elements of packaging including flavor
descriptors and corporate branding. The findings are consistent with research on cigarettes
showing that characteristics of package design convey information to consumers about
the product [14,17,20,21,31]. Because this research demonstrated that packaging elements are particularly salient
among youth and young adults, it highlights the importance of accurately conveying
health risk information among those most susceptible to tobacco use uptake.

Competing interests

Richard J. O’Connor (RJO) has served as a consultant to the Tobacco Constituents Subcommittee
of the Tobacco Products Scientific Advisory Committee (TPSAC) of the U.S. Food and
Drug Administration. RJO, via a subcontract from Research Triangle Institute, reviewed
confidential and trade secret documents on menthol cigarettes submitted by tobacco
manufacturers pursuant to an FDA request, and presented this information in closed
session to TPSAC (10 Feb 2011); this information was not used in any way in the current
study.

Authors’ contributions

SA performed the statistical analysis, and wrote the first draft and revised the manuscript.
MBT developed the study and its design, led data collection efforts, and contributed
to the manuscript and interpretation of the data. RJO and DS contributed to the manuscript
and provided assistance in interpretation of results. AH participated in the design
of the study and revising the manuscript. All authors read and approved the final
manuscript.

Acknowledgements

We would like to acknowledge and thank Dr. K. Michael Cummings for his contribution
to the study design and protocol development.

Funding

Data collection for this study was funded by the NCI-funded Roswell Park TTURC, P50
CA111236 (PI Cummings). The preparation of this article has been supported by Federal
funds from the National Institute on Drug Abuse, National Institutes of Health, and
the U.S. Food and Drug Administration, Department of Health and Human Services, under
Contract No. HHSN271201100027C. The views and opinions expressed in this document
are those of the authors only and do not necessarily represent the views, official
policy or position of the U.S. Department of Health and Human Services or any of its
affiliated institutions or agencies.

Hammond D, Fong GT, McNeill A, Borland R, Cummings KM: Effectiveness of cigarette warning labels in informing smokers about the risks of
smoking: findings from the International Tobacco Control (ITC) Four Country Survey.

Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General.
Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control
and Prevention, National Center for Chronic Disease Prevention and Health Promotion,
Office on Smoking and Health. 2012.